The Joint Commision's
Melody F. Dickerson

Q&A : The Joint Commission's Melody Dickerson

October 15, 2010
by Brendon Nafziger, DOTmed News Associate Editor
The Joint Commission hopes an interactive online tool will help hospitals fight one of health care's dirtiest problems: hand-washing.

Launched last month, the Targeted Solution Tool, available at no cost to Joint Commission-accredited institutions, could help hospitals track and improve hand-washing compliance.

While it appears simple on its face, achieving hand-washing compliance has been devilishly tricky in practice. In fact, some estimate that people in public bathrooms are more likely to wash their hands than health care providers - a survey last month found around 85 percent of public bathroom users washed up afterward. But only between a quarter and one-third of health care professionals followed proper hand hygiene protocols, according to a 2009 American Journal of Medical Quality report.

"[T]he guy who just used the toilet at Grand Central Station is...way more likely to have clean hands than the guy walking up to your bed at the local hospital," Michael L. Millenson wrote last month in the Health Care Blog.

Of course, lack of hand-washing has consequences, such as helping to spread disease. And the scale of health care-acquired infections is immense. In a talk last year, The Joint Commission president Dr. Mark Chassin said the number of deaths in the United States every year from health care-associated infections was the mortality equivalent of a 767 crashing and killing everyone on board, every day of the year.

Looking for answers

Last year, The Joint Commission launched the Joint Commission Center for Transforming Healthcare, to solve health care safety and quality problems. One of the fruits of this work is the Targeted Solutions Tool, an online application accessible for TJC-accredited hospitals (via their extranet account).

From feedback from the first eight hospitals involved in the program, the commission decided hand hygiene would be the first target (a set of solutions for hand-off communications will be announced next week and solutions to prevent wrong-site surgery are expected to be released this spring).

The tool works like this: some staff are picked to be observers and report on the hand hygiene performance of their coworkers. They either input their reports directly into a computer or jot it down on a printout and later feed it into the website.

The tool then creates a confidential report so hospitals can track their hygiene and find out weaknesses they can improve upon. And results come quickly, TJC says. The whole process takes about six to 12 weeks.

And, apparently, it works. For the eight leading hospitals, hand hygiene compliance averaged 48 percent in April 2009. But by June 2010, after the program started, it reached 82 percent, TJC says.

To learn more about the system and how well the results will apply to smaller hospitals, DOTmed News spoke with Melody F. Dickerson, a certified Six Sigma "Black Belt" with the Joint Commission's Center for Transforming Healthcare. Prior to joining the center, Dickerson helped implement the center's hand hygiene project at Wake Forest University Baptist Medical Center.

DOTmed News: Why did The Joint Commission choose hand hygiene compliance as the first solution?

Melody Dickerson: We actually selected the eight hospitals first. They were selected because they all have the common thread of robust process improvement, specifically a lean Six Sigma program in their organization.

So once we selected the eight hospitals the question was posed to them: what was the number-one patient safety challenge? Notice I didn't say your hardest Joint Commission standard. They actually responded that hand hygiene was the biggest challenge. That is probably the result of the standard at the time, which said you had to show you had hygiene compliance of 90 percent or higher. That standard was actually changed as the result of this project, because once we collected our baseline measurements, it became painfully clear that 90 percent was a bit of a lofty goal...And some of the places that were actually demonstrating it were creative with how they were collecting their data.

DN: The tool gives hospitals charts - how does this help hospitals track their hand-washing compliance?

MD: They get three kinds of charts. First, a proportion control chart, which are compliance rates over time. They can filter it by day of the week, day-shifts compared to night-shifts and also a filter for entry versus exit.

The second chart is a Pareto chart: the Pareto chart is looking at the more common contributing factors, ranking from most common to least common. That's what drives targeted solutions. You'll get the solutions in those ranked orders.

The third chart is an analysis of means, and the analysis of means chart compares different health care worker types and looks at variation among groups and looks at number of data points that you have. And it really is a good way comparing groups, to say, for instance, that you know housekeeping is statistically significantly more likely to have a hand hygiene defect - not washing their hands - than other groups. It can also tell you if one group is statistically significantly better than other groups.

DN: For the hospitals that worked with this, what are some of the recommendations that come out of the solution?

MD: What we found was there are about 14 different reasons why people don't wash their hands, ranging from distraction to the hand sanitizer dispensers being empty to wearing gloves instead of washing your hands. Another problem was "follow the leader:" I'm walking with you into a room and you don't wash your hands, so I'm not going to wash my hands either.

Each organization measures those things so they would be able to figure out the most common causes of failure within their pilot areas. Once those were identified, they created the solutions and tested them and were found to have rigor as far as impacting those causes and resulting in improved hand hygiene compliance.

For instance, if someone's walking into a room with their hands full of supplies, they can forget to wash their hands. So, you create a drop spot: you designate a spot in the room that is considered for medical-use only, where those items can be set down. Patients and family members have to be educated that they leave that area clear for health care workers. So now they have a space to set down supplies, and within arms' reach is an alcohol-based hand sanitizer dispenser.

DN: How many hospitals are participating in it today?

MD: After the eight hospitals did their work, then we actually piloted it in 27 different organizations. They ranged in size form large academic medical centers down to 25-bed critical access hospitals. They're demonstrating improvements. Now we have folks starting to use the tools, and many are rolling this out to their entire organization.

DN: The project started with hospitals with a lot of resources like Memorial Hermann in Texas and Johns Hopkins. Do you think the results are transferable to smaller hospitals?

We think it will be really good for smaller organizations...We have a downloadable, self-supporting, training module for the data collection tool. It has a test that staff can take: we've given them posters and other support that they can download and use. If you're a staff nurse on a unit, there's no way you'd have the resources to do that on your own. I think it's really geared toward the smaller organization that lacks resources because you have this whole program ready to go: all they have to do is do it.

DN: Does choosing some staff to be observers who report hand hygiene performance create any hostility or mistrust among the staff?

MD: When staff see you going out and implementing solutions to now make it easier for them to wash their hands, it takes the stigma off. It becomes an "ah-ha moment," it's like they really do understand, that this is hard. You know: over time, you'll see the whole culture change. Now, they're not just washing their hands more, they're cleaning equipment in patient rooms that they hadn't done before because now they start getting it. Most places when they have done a "hand hygiene" project, it has all been about collecting the Yes or No's - did you wash your hands? And it's all been trying to lead by intimidation. But this is different.